197608505-9-1-2023-31-AS-NMAN-CVNRW4-20230914132232

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 09/01/2023
Date Signed: 09/01/2023 11:00:54 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/25/2023 and conducted by Evaluator Antonia Alvizar

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230525153815

FACILITY NAME:	GLEN PARK AT GLENDALE - BOYNTON ST		FACILITY NUMBER:	197608505
ADMINISTRATOR:	PINK, JR, TILLMAN		FACILITY TYPE:	740
ADDRESS:	1250 BOYNTON ST		TELEPHONE:	(818) 246-9000
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	98	CENSUS: 64	DATE:	09/01/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator, Peter Bonilla		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff provided a resident with an illegal drug while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Antonia Alvizar conducted unannounced complaint visit to the facility to deliver finding for the above noted allegation.

It was alleged that while R1 was admitted at the hospital, for low blood pressure they run tests and found Fentanyl in R1’s urine.

Initial investigation was conducted by the LPA Laqueena Lacy and Senior Investigator Christine Ferris assisted LPA with this investigation.
On 05/26/2023 at 3:45pm and 06/12/23, LPA Lacy and investigator Ferris attempted to speak (R1) and R1 was unable to respond to the questions. On 05/26/23 and 06/12/23 LPA and investigator spoke with the Administrator who indicated that prior to hospitalization in May 2023, R1 was on hospice and due to declining health was taking controlled medication Hydrocodone.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230525153815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT GLENDALE - BOYNTON ST	FACILITY NUMBER: 197608505
	VISIT DATE: 09/01/2023

NARRATIVE

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R1 was only receiving prescribed medication and Fentanyl was not one of them. Administrator denied any staff giving any medication to R1 other than prescribed medication.

On 06/08/2023 Investigator reviewed R1’s hospital records, indicating following information. Between 05/24/23 and 05/28/23 R1 was hospitalized two times. 1^st time on 05/24/23, no toxicology tests were performed on 05/27/23, Toxicology urine analysis was conducted, and the result showed "opioid detected." No testing for fentanyl was conducted. As per doctor’s notes, "though R1’s drug screen was positive for opiates, it was likely secondary to prescribed opiate medication." A review of medication Administrator Records revealed that R1 was prescribed an opioid medication.

Based on interviews and record review, there is no sufficient information or evidence supporting the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No immediate health and safety hazard noted during this visit.

Exit interview was conducted and a copy of report was issued to Administrator, Peter.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC9099 (FAS) - (06/04)

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